Clinical and radiological outcomes of a modified anatomic posterolateral corner reconstruction technique using a single semitendinosus autograft.

PURPOSE: We aimed to assess the clinical and radiological outcomes of a modified anatomical posterolateral corner (PLC) reconstruction technique using a single autograft. METHODS: This prospective case series included 19 patients with a posterolateral corner injury. The posterolateral corner was reconstructed using a modified anatomical technique that utilized adjustable suspensory fixation on the tibial side. Patients were evaluated subjectively using the international knee documentation form (IKDC), Lysholm, and Tegner activity scales and objectively by measuring the tibial external rotation angle, knee hyperextension, and lateral joint line opening on stress varus radiographs before and after surgery. The patients were followed-up for a minimum of 2 years. RESULTS: Both IKDC and Lysholm knee scores significantly improved from 49 and 53 preoperatively to 77 and 81 postoperatively, respectively. The tibial external rotation angle and knee hyperextension showed significant reduction to normal values at the final follow-up. However, the lateral joint line opening measured on the varus stress radiograph remained larger than the contralateral normal knee. CONCLUSION: Posterolateral corner reconstruction with a hamstring autograft using a modified anatomical reconstruction technique significantly improved both the subjective patient scores and objective knee stability. However, the varus stability was not completely restored compared with the uninjured knee. LEVEL OF EVIDENCE: Prospective case series (Level of evidence IV).

Incidence and risk factors of ipsilateral shoulder pain in patients after thoracic surgeries.

Background and Aims: Ipsilateral shoulder pain (ISP) post-thoracotomy impairs the recovery in early postoperative period, the aetiology of which is unclear. We studied to find out the incidence and risk factors associated with ISP. Methods: We did a prospective observational study, wherein 296 patients scheduled for thoracic surgeries were enroled. Pain in the shoulder during activity was assessed using American Shoulder and Elbow Surgeons standardised assessment method. All potential predictors were analysed in a multivariable penalised logistic regression model, using ISP as the outcome variable. Results: Of the 296 patients, 118 (39.8%) patients developed ISP. Of the 296 patients, 170 patients underwent thoracotomy and 110 underwent video-assisted thoracoscopic surgeries. The incidence of ISP was higher in thoracotomy patients (45.29%) compared to video-assisted thoracoscopic surgeries (32.7%). Majority of patients (43.2%) were aged more than 65 years, which was statistically significant as per univariate analysis (P = .007). The incidence of ISP was the highest at 41.89% among those who had lung cancer (n = 74), with disease involving right upper lobe and left upper lobe, 29% and 25.8%, respectively. The pain severity was moderate in 27.1% of patients during shoulder movements. Among the patients who had ISP, 77.1% expressed it as dull aching, whereas 21.2% described it as stabbing in nature. Conclusion: The incidence of ISP in those who underwent thoracic surgery was high and dull aching in nature, of mild to moderate intensity, commonly located on the posterior aspect of the shoulder. It was more common in those who underwent thoracotomy and more than 65 years of age.

Ileocecal junction: anatomic, histologic, radiologic and endoscopic studies with special reference to its antireflux mechanism.

AIM: The aim of the study was to perform histomorphologic, endoscopic, and radiologic studies of the ileocecal junction (ICJ). A clearer understanding of the anatomical structure of the ICJ may shed some light on its function. METHODS: Histomorphologic studies were performed in 18 cadavers and radiologic in 22 and endoscopic in 10 healthy volunteers. Morphologic studies were done with the help of a magnifying loupe: histologic sections were stained with hematoxylin and eosin and Masson's trichrome. The ICJ was studied radiologically using the method of small bowel meal. Endoscopic study was done under controlled air inflation using a video endoscope. RESULTS: A nipple (1.5-2 cm long) with transversely lying stoma protruded from the medial wall of the cecum. A fornix was found on each side. The nipple stoma was surrounded by two lips: upper and lower. A mucosal fold started at both angles of the stoma and extended along the cecal circumference. It was marked on the outer cecal aspect by a groove. CONCLUSION: The ileocecal nipple is a muscular tube with a transversely lying stoma and is suspended to the cecal wall by a "suspensory ligament". The morphologic structure of the ileocecal nipple was confirmed endoscopically and radiologically. The ileocecal nipple was closed at rest and opened upon terminal ileal contraction to deliver ileal contents to the cecum. It evacuated the barium periodically into the cecum. The ileocecal nipple structure seems to be adapted to serve the function of cecoileal antireflux.

A study of an anatomic-physiological cecocolonic sphincter in humans.

We hypothesized an anatomical/physiological sphincter and investigated this hypothesis in current communication. The histomorphologic and morphometric studies were carried out in 14 cadavers and radiologic studies in 20; endoscopy studies were done in 16 healthy volunteers. Longitudinal sections along cecum, cecocolonic junction, and ascending colon were stained with H & E and Masson's trichrome stain. Morphometry study of musclethickness of cecum, cecocolonic junction, and ascending colon, radiological examination by method of small bowel barium meal administration, and endoscopic study by pancolonoscopy were studied. A cecocolonic fold was identified 2-2.5 cm distal to ileocecal nipple. It extended along gut circumference, shelf-like, and was marked by a shallow groove on outer aspect of colon. Microscopically, cecocolonic fold consisted of mucosa, submucosa, and muscularis externa. The circular muscle layer was thicker than that of cecum or ascending colon. Branching cells with ovoid nuclei representing probably intestinal cells of Cajal were identified in muscularis externa. Also morphometric study showed that circular muscle layer was significantly thicker than that of cecum or ascending colon, whereas longitudinal muscle exhibited no significant difference. Radiologic studies demonstrated narrowing at cecocolonic junction, which became wider on cecal contraction and narrower or closed on colonic contraction. Endoscopically, cecocolonic junction was narrow due to presence of cecocolonic fold, which exhibited spontaneous contractions. Our findings suggest an "anatomic" sphincter at cecocolonic junction as evidenced histomorphometrically, radiologically and endoscopically. Detection of interstitial cells of Cajal in cecocolonic fold postulates possible existence a pacemaker in cecocolonic fold, a point that needs further study.

Double-loop puborectoplasty: novel technique for the treatment of fecal incontinence.

The treatment of neurogenic and traumatic fecal incontinence (FI) as may result from severe anal sphincteric destruction is problematic. A novel technique for the treatment of these cases is presented. The study comprised 44 patients, which included 28 with neurogenic and 16 with traumatic FI. Patients were divided into two equal groups. Two fascia lata slings (FLS) were applied in Group 1, while one sling was used in Group 2. Investigations comprised manometric and electromyographic studies. The procedure consisted of performing a curvilinear incision behind the anal orifice, and the supralevator region was entered. The middle of an FLS was sutured to the back of the upper part of anal canal. Each of the two limbs of the sling was passed forward through an incision on the pubic ramus and was sutured to the periosteum of the pubic ramus. This was preformed in Groups 1 and 2. A second FLS was added in Group 1. Its center was sutured to the front of the mid anal canal and its two limbs to the coccyx. Satisfactory results (continence scores 1 and 2) were obtained in 63.6% of Group 1 and 36.4% of Group 2. Significant postoperative anal pressure increase occurred in scores 1 to 3 in Group 1 and in scores 1 to 2 in Group 2. Anal pressure increase was more prominent in Group 1 than in Group 2. The continent effect of the operation appears to be due to the increase of anal pressure, anal canal elongation, and recto-anal angulation. The operation is indicated in FI of the idiopathic or traumatic type with excessive sphincteric loss. It is simple and easy and performed under no cover of colostomy.

Effect of severe stress on the gastric motor activity: canine study of mechanism of action.

BACKGROUND: Increased gastric motility was observed during restraint stress in animals; however, mechanism of action could not be traced in literature. We investigated the hypothesis that high levels of stressful cutaneous stimuli induce increase of gastric motor activity through a reflex action. METHODS: Gastric tone (GT) was assessed in 14 dogs by barostat system consisting of balloon-ended tube connected to strain gauge and air-injection system. Tube was introduced into stomach and its balloon inflated with 150 mL of air. Thermal cutaneous stimulation (TCS) was performed by thermal plate applied to skin. Temperature was raised in increments of 5 degrees C up to 107 degrees C and GT was simultaneously assessed by recording balloon volume variations expressed as percentage change from baseline volume. Test was repeated after separate anesthetization of skin and stomach. RESULTS: TCS up to mean temperature of 48.7 +/- 1.1 degrees C effected significant decrease of GT, but significant increase beyond this temperature. Twenty minutes after individual anesthetization of skin and stomach, TCS produced no significant change in GT. CONCLUSION: TCS up to certain degree effected GT decrease, whereas TCS beyond this degree augmented the GT. These effects seem to be mediated through reflex action as evidenced by their absence on individual anesthetization of the suggested 2 arms of the reflex arc: skin and stomach; we call this reflex "cutaneo-gastric reflex." The reflex may have the potential to serve as an investigative tool in diagnosis of gastric motor disorders provided further studies are performed to reproduce current results.

An electrophysiologic study of female ejaculation.

Opinions vary over whether female ejaculation exists or not. We investigated the hypothesis that female orgasm is not associated with ejaculation. Thirty-eight healthy women were studied. The study comprised of glans clitoris electrovibration with simultaneous recording of vaginal and uterine pressures as well as electromyography of corpus cavernous and ischio- and bulbo-cavernosus muscles. Glans clitoris electrovibration was continued until and throughout orgasm. Upon glans clitoris electrovibration, vaginal and uterine pressures as well as corpus cavernous electromyography diminished until a full erection occurred when the silent cavernosus muscles were activated. At orgasm, the electromyography of ischio-and bulbo-cavernosus muscles increased intermittently. The female orgasm was not associated with the appearance of fluid coming out of the vagina or urethra.

Colosigmoid junction: morphohistologic, morphometric, and endoscopic study with identification of colosigmoid canal with sphincter.

To study the anatomical structure of the colosigmoid junction, 15 cadaveric specimens were studied morphologically, another 15 histologically, and a morphometric study was done in 10 specimens. Specimens consisted of the descending colon, sigmoid colon, and the colosigmoid junction. Histologic specimens were stained with hematoxylin and eosin and Masson's trichrome stain. Morphometric studies used an image analysis system. The colosigmoid junction was investigated endoscopically in 18 healthy volunteers. A narrow segment having a mean length of 5.2 +/- 1.1 cm was identified both externally and internally between the descending and sigmoid colon. We called this segment the colosigmoid canal. Mucosal folds were found crowded in the colosigmoid canal, the lower end of which formed a nipple and was surrounded by a fornix. Histologically, the colosigmoid canal mucosa showed multiple folds. Its circular muscle was thicker than that of the descending or the sigmoid colon and confirmed morphometrically. The longitudinal muscle was thicker in only 4 of 10 specimens. Both the narrowing and the mucosal crowding were verified endoscopically. The colosigmoid junction is the narrow segment between the descending and the sigmoid colon. Histologic, morphometric and endoscopic studies indicated the presence of a sphincter in the colosigmoid canal. A colosigmoid sphincter is suggested to control the passage of colonic contents from the descending colon to the colosigmoid canal as well as to prevent reflux of sigmoid contents into the descending colon.

Percutaneous perineal electrostimulation induces erection: clinical significance in patients with spinal cord injury and erectile dysfunction.

OBJECTIVES: Approximately one third to one half of the penis is embedded in the pelvis and can be felt through the scrotum and in the perineum. The main arteries and nerves enter the penis through this perineal part of the penis, which seems to represent a highly sensitive area. We investigated the hypothesis that percutaneous perineal stimulation evokes erection in patients with neurogenic erectile dysfunction. METHODS: Percutaneous electrostimulation of the perineum (PESP) with synchronous intracorporeal pressure (ICP) recording was performed in 28 healthy volunteers (age 36.3 +/-7.4 y) and 18 patients (age 36.6 +/- 6.8 y) with complete neurogenic erectile dysfunction (NED). Current was delivered in a sine wave summation fashion. Average maximal voltages and number of stimulations delivered per session were 15 to 18 volts and 15 to 25 stimulations, respectively. RESULTS: PESP of healthy volunteers effected an ICP increase (P < 0.0001), which returned to the basal value upon stimulation cessation. The latent period recorded was 2.5 +/- 0.2 seconds. Results were reproducible on repeated PESP in the same subject but with an increase of the latent period. Patients with NED recorded an ICP increase that was lower (P < 0.05) and a latent period that was longer (P < 0.0001) than those of healthy volunteers. CONCLUSION: PESP effected ICP increase in the healthy volunteers and patients with NED. The ICP was significantly higher and latent period shorter in the healthy volunteers than in the NED patients. PESP may be of value in the treatment of patients with NED, provided that further studies are performed to reproduce these results.

Effect of thermal cutaneous stimulation on the gastric motor activity: study of the mechanism of action.

AIM: To investigate the mechanism of action of thermal cutaneous stimulation on the gastric motor inhibition. METHODS: The gastric tone of 33 healthy volunteers (20 men, mean age 36.7 +/- 8.4 years) was assessed by a barostat system consisting of a balloon-ended tube connected to a strain gauge and air-injection system. The tube was introduced into the stomach and the balloon was inflated with 300 mL of air. The skin temperature was elevated in increments of 3 degree up to 49 degree and the gastric tone was simultaneously assessed by recording the balloon volume variations expressed as the percentage change from the baseline volume. The test was repeated after separate anesthetization of the skin and stomach with lidocaine and after using normal saline instead of lidocaine. RESULTS: Thermal cutaneous stimulation resulted in a significant decrease of gastric tone 61.2% +/- 10.3% of the mean baseline volume. Mean latency was 25.6 +/- 1.2 ms. After 20 min of individual anesthetization of the skin and stomach, thermal cutaneous stimulation produced no significant change in gastric tone. CONCLUSION: Decrease in the gastric tone in response to thermal cutaneous stimulation suggests a reflex relationship which was absent on individual anesthetization of the 2 possible arms of the reflex arc: the skin and the stomach. We call this relationship the "cutaneo-gastric inhibitory reflex". This reflex may have the potential to serve as an investigative tool in the diagnosis of gastric motor disorders, provided further studies are performed in this respect.

The anterolateral abdominal wall muscles during vesical filling and evacuation: electromyographic study.

OBJECTIVES: The role of the anterolateral abdominal wall muscles (AAWM) during vesical filling and evacuation has not been sufficiently addressed in the literature. We investigated the hypothesis that the AAWM exhibit increased electromyographic (EMG) activity on vesical distension and contraction that presumably assists in vesical evacuation. METHODS: The effect of vesical balloon distension on vescial (VP) and vesical neck (VNP) pressures and on AAWM EMG activity was studied in 28 healthy volunteers of age 40.7 +/- 9.7 years (18 men and 10 women). This effect was tested after anesthetization on individual vesical and AAWM and after saline infiltration. RESULTS: The VP and VNP showed gradual increase on incremental vesical balloon distension starting at a distending volume of 120 to 140 mL. At a mean volume of 364.6 +/- 23.8 mL, the VP increased to a mean of 36.6 +/- 3.2 cm H(2)O, the VNP decreased to 18.4 +/- 2.4 cm H(2)O, and AAWM EMG registered a significant increase. This effect disappeared with anesthetization on individual vesical or AAWM, but not with saline administration. CONCLUSIONS: AAWM appear to contract simultaneously with vesical contraction; this action presumably increases the intra-abdominal pressure and assists vesical contraction. The AAWM contraction on vesical contraction seems to be mediated through a reflex that we call the "vesico-abdominal wall reflex." Further studies are required to investigate the role of this reflex in vesical disorders.

Vaginal response to clitoral stimulation: identification of the clitorovaginal reflex.

OBJECTIVE: To investigate the hypothesis that glans clitoris (GC) penile buffeting effects contraction of the vaginal musculature and seems to increase arousal of the penis during coitus. STUDY DESIGN: The response of the vaginal wall to GC electrical and mechanical stimulation was recorded in 26 healthy women (aged 36.8 +/- 6.7 years). The test was repeated after individual anesthetization of the GC and vagina using lidocaine gel and after application of bland gel instead of lidocaine. RESULTS: The 2 vaginal electrodes recorded, at rest, slow waves followed or superimposed by action potentials. Wave parameters were similar from the 2 electrodes. Electrical or mechanical GC stimulation effected a significant increase in vaginal electromyographic (EMG) activity and pressure (p < 0.01). GC stimulation, while the vagina or GC had been separately anesthetized, produced no significant change, but there was a response following application of bland gel. CONCLUSION: GC stimulation effected an increase in vaginal EMG activity and pressure and presumably indicated vaginal wall contraction. This action seems to be a reflex and is mediated through the clitorovaginal excitatory reflex. Vaginal wall contraction during coitus appears to effect penile arousal and, consequently, female sexual stimulation.

Study of the response of the penile corporal tissue and cavernosus muscles to micturition.

BACKGROUND: The reaction of the corpora cavernosa (CC), the corpus spongiosum (CS), the bulbocavernosus (BCM) and ischiocavernosus (ICM) muscles to passage of urine through the urethra during micturition is not known. We investigated the hypothesis that the passage of urine through the urethra stimulates the corporal tissue and cavernosus muscles. METHODS: In 30 healthy men (mean age 42.8 +/- 11.7 years), the electromyographic activity (EMG) of the CC, CS, BCM, and ICM were recorded before and during micturition, and on interruption of and straining during micturition. These tests were repeated after individual anesthetization of urethra, corporal tissue, and cavernosus muscles. RESULTS: During micturition, the slow wave variables (frequency, amplitude, conduction velocity) of the CC and CS decreased while the motor unit action potentials of the BCM and ICM increased; these EMG changes were mild and returned to the basal values on interruption or termination of micturition. Micturition after individual anesthetization of urethra, corporal tissue and cavernosal muscles did not effect significant EMG changes in these structures, while saline administration produced changes similar to those occurring before saline administration. CONCLUSION: The decrease of sinusoidal and increase of cavernosus muscles' EMG activity during micturition apparently denotes sinusoidal relaxation and cavernosus muscles contraction. Sinusoidal muscle relaxation and cavernosus muscles contraction upon micturition are suggested to be mediated through a 'urethro-corporocavernosal reflex'. These sinusoidal and cavernosus muscle changes appear to produce a mild degree of penile tumescence and stretch which might assist in urinary flow during micturition.

Inguinal canal dilatation: a novel technique for the repair of failed testicular descent despite hormonal treatment.

Treatment of the undescended testicle (UT) after it failed to descend on hormonal therapy is surgical. Spermatic cord elongation may impair testicular function, particularly in cases in which cord integuments or veins have to be divided to provide an extra cord length. A factor that might impede testicular descent is presence of a narrowed or obliterated inguinal canal. We investigated the hypothesis that dilatation of a narrowed or obliterated inguinal canal might assist spontaneous testicular descent. Twenty-six boys (age 3.6 +/- 0.8 years) with unilateral UT and failed hormonal treatment, whose UT was located at deep inguinal ring, were included in the study. Through an inguinal incision, the inguinal canal was dilated, spermatic cord adhesions divided, hernial sac, if present, excised, and skin closed. Testicular descent into the scrotum occurred in 22 patients within 4.2 +/- 1.3 months. The remaining four patients were reoperated on by Fowler-Stephens orchiopexy after 14 months. A technique is presented for the treatment of the UT after failure to respond to hormonal treatment. It consisted of clearing the testicular pathway of any adhesions and dilating the narrowed inguinal canal. The technique is simple, easy, and does not interfere with the testicle or spermatic cord.

Effect of micturition on clitoris and cavernosus muscles: an electromyographic study.

We investigated the hypothesis that passage of urine through urethra stimulates corporal tissue and cavernosus muscles. Electromyographic (EMG) activity of corpora cavernosa (CC), bulbocavernosus muscle (BCM), and ischiocavernosus muscle (ICM) was recorded in 27 healthy women before and during micturition. These tests were repeated after individual anesthetization of urethra, corporal tissue, and cavernosus muscles. During micturition, slow wave variables of CC decreased and motor unit action potentials of the BCM and ICM increased. These EMG changes returned to basal values on micturition interruption or termination. Micturition after individual anesthetization of the urethra, corporal tissue, and cavernosus muscles did not effect significant changes in these structures. Decreased EMG activity of CC and increased activity of cavernosus muscles during micturition apparently denotes corporal tissue relaxation and cavernosus muscles' contraction. The latter two actions occurring on micturition are suggested to be mediated through a reflex called "urethro-corporocavernosal reflex" and effect a mild degree of clitoral tumescence.

The electromyographic activity of the external and internal urethral sphincters and urinary bladder on vaginal distension and its role in preventing vaginal soiling with urine during sexual intercourse.

BACKGROUND/AIM: We investigated the hypothesis that external (EUS) and internal (IUS) urethral sphincters and urinary bladder (UB) respond to penile thrusting (PT) of vagina in a way that prevents urinary leakage during coitus. METHODS: Vaginal condom was inflated with air in increments of 50-300 ml and EMG of EUS and IUS and vaginal pressure were recorded; test was repeated after anesthetization of vagina, UB, EUS, and IUS. RESULTS: Vaginal distension effected reduction of vesical pressure but increase of IUS EMG until the 150 ml distension was reached, beyond which more vaginal distension caused no further effect; EUS EMG showed no response. Vaginal distension while vagina, UB, EUS, and IUS had been separately anesthetized, produced no change. CONCLUSION: Vaginal balloon distension appears to effect vesical relaxation and increased IUS tone. This seems to provide a mechanism to avoid urine leakage during coitus and to occur through a reflex we term 'vagino-urethrovesical reflex'.

Electromyographic lag time and opening time: two novel noninvasive methods to investigate patients with anal outlet obstruction and their response to treatment.

Methods in use can diagnose anal outlet obstruction but not degree of obstruction. We introduced two novel noninvasive methods of diagnosing and evaluating the degree of anal outlet obstruction: pelvic floor electromyographic lag time and opening time. Pelvic floor electromyographic lag time measured time interval between start of pelvic floor muscle relaxation and start of anal outlet flow. Opening time calculated time lapse between start of rectal contraction and start of anal outlet flow. We investigated the hypothesis that pelvic floor electromyographic lag time and opening time can be used as investigative tools in diagnosing and evaluating degree of anal outlet obstruction. Thirty-one patients with anal outlet obstruction and 26 healthy volunteers were studied. Electromyography of external anal sphincter and anal and rectal pressures were recorded on rectal balloon distension until balloon was expelled. Pelvic floor electromyographic lag time and opening time were measured. Mean opening time and pelvic floor electromyographic lag time of the anal outlet obstruction patients showed significant increase compared to those of healthy volunteers. Pelvic floor electromyographic lag time was longer than opening time in both patients and controls, but the difference was not significant. Biofeedback effected improvement in 24 of the 31 patients. Thus, two novel investigative tools -- opening time and pelvic floor electromyographic lag time -- in diagnosis of anal outlet obstruction are presented. They exhibited significant increase in anal outlet obstruction patients over the healthy volunteers. There was no significant difference between pelvic floor electromyographic lag time and opening time readings.

Effect of urethral stimulation on vesical contractile activity.

BACKGROUND: We investigated the hypothesis that urethral stimulation effects vesical contraction. METHODS: Vesical pressure response to urethral balloon distension with normal saline in increments of 1 mL was recorded in 26 healthy volunteers (17 men, 9 women; mean age, 36.9 +/- 9.7 SD years) before and after individual anesthetization of the urinary bladder and urethra. Urethral distension was effected by a 6F balloon-ended catheter introduced per urethra. Vesical pressure was measured by means of a microtip catheter. RESULTS: Vesical pressure recorded gradual increase on increase of urethral balloon distension. Bladder response was maintained as long as urethral distension was continuous. The response showed no significant difference when we distended different parts of the male or female urethrae. Urethral distension after individual vesical and urethral anesthetization effected no change in the vesical pressure. CONCLUSIONS: Urethral distension produced a vesical pressure increase that presumably denotes vesical contraction. Vesical contraction on urethral stimulation by distension is suggested to be mediated through a "urethrovesical stimulating reflex" that seems to facilitate vesical contraction. Provided further studies to be performed in this respect, the reflex may prove to be of diagnostic significance in micturition disorders.